The Looking Glass World

How COVID Emergency morphed into COVID Entropy

Anyone who has ventured out of their cave in the last few weeks must sense that there is a disconnect between what the CDC is telling us about the prevalence of COVID in our communities and the reality of what we see and hear. US cases have continued to rise steadily, approximately doubling in the last last two weeks to 90,000 a day. Hospitalizations are also steadily increasing, showing a 15.4% increase in the 7 day average from the prior 7 day period. That seems significant to me. Despite this, the CDC map of community level of COVID by counties is a pleasing green, with the exception of the northeast and north central regions. Haven’t we been here before- several times no less. Waves of disease starting on the coasts, the northeast in particular, and then marching across the country. By way of anecdote, which I usually avoid here, the following incident seems to capture what many people are experiencing. Several weeks ago, a close friend had a dinner party prior to his daughter’s wedding. All 80 guests had to be triple vaccinated. The morning after the dinner one of the guests reported being ill and had a positive rapid COVID test. During the next week or so 46 of the 80 guests tested positive.

We know of course that the transition to rapid home testing and the demise of large scale public health PCR testing means that only the tip of the iceberg of positive tests are being reported. The true count of new daily infections is vastly higher than the 90,000 and rising. But there is no sense of urgency from the CDC or the Administration, and there should be. We know what is driving the upsurge in cases again, it is the offspring of Omicron, first BA.2, but now BA.2.12.1, which is poised to become the dominant virus nation wide in one to two weeks, after rapidly outcompeting the others. These variant surges can be traced to three factors, a higher level of immune evasion, decreased effectiveness of the vaccines (a corollary of the first item) and the prevailing Zeitgeist of the moment. This looking glass world is summed up by the following: We are all just tired of this, you are now in the phase of “Living with COVID”, we are not ready, willing or able to track cases anymore-so we will count only hospitalizations and deaths, if you are vaccinated and boosted then COVID will just be a cold. All sounds pretty good after two and a half years of this, but it’s wishful thinking, and that has not been very helpful so far as a strategy for confronting the Pandemic.

So what’s wrong with approach described above and how may it come back to bite us? Professor Eric Topol points out in yesterday’s, excellent substack post (Ground Truth/ The COVID Capitulation) that the SARS2-Cov19 virus seems to have entered an accelerated phase of evolution with the much more rapid appearance of variants causing world wide surges than we had observed during the first 2 years. For a while it seemed we were progressing at a steady pace through the Greek alphabet with the goal of Omega in site, but now a rapid fire parade of un-alphabetized BA.. variants have spread quickly across the globe. The message from the government to many folks seems to be: “Pay no attention to that, if you’re vaccinated and boosted two or three times, just take it upon yourself to know the local disease prevalence, you have nothing to worry about”. That is not true even on an individual level, and even less so at a societal level. The principals of viral molecular evolution argue strongly that unrestrained spread of the virus is the breeding ground of new variants, which are constantly now being selected for their ability to evade existing population immunity. It has been strongly suspected for quite a while that chronic infection with the virus in immunologically compromised individuals is the basis for the appearance of radical, highly divergent new variants. The recent spate of variants beginning with BA.1 Omicron have all appeared in South Africa, and as Professor Francis Barany of Weil Cornell University Medical School recently pointed out to me; that should come as no surprise since 20% of the population is HIV positive, or 12 million people. That’s a gigantic reservoir of unfathomable numbers of viral replication events for evolution to tinker with. We have in the US an estimated 7 million immunocompromised people, and that’s not counting the many millions more who are naturally compromised by age. Allowing unrestrained replication of the virus, even if it’s true that many fewer people are dying than earlier, does not seem like a good plan, or any real plan.

Ok, great-so what can we do about it? Stricter non-pharmacologic mitigation efforts seem to be off the table now; after all we are all so very tired, and there are mid-term elections to think about. Even the simpler scaled down mitigation efforts like masks, which do reduce transmission and don’t stall the economy (no matter what it says on a social media account), are basically a no-go politically at this point. The CDC’s advice is basically: “Use a mask if you want to, or…. Smoke ‘em if you got ‘em”. We have just reviewed the fact that the CDC estimates of disease prevalence are dramatically out of phase with reality, so how likely are they to help you accurately judge local risk if you are inclined to wear a mask? I have said this previously, and Eric Topol agrees, the most important direction we can take now is the concerted effort to develop more effective vaccines that stop the transmission of COVID. It’s time for the government to stop the nonsense that this is a Pandemic of the unvaccinated. Also time to face the facts that Omicron and its derivatives have now sufficiently escaped vaccine induced immunity that protection from severe disease and death, for the vaccinated and boosted, has declined from the upper nineties to 80%. How that translates to more readily discernible numbers can be seen in the KFF analysis of CDC data. (Kaiser Family Foundation)

From October through February there has been a steady increase in the percentages of overall deaths among the vaccinated and boosted, with the most dramatic increase occurring from December through February, and corresponding to the Omicron era. This is not because many more people became vaccinated during the interval, that group only increased by 6%. But unfortunately, the percentage of deaths occurring in the boosted demographic went from 2% in October to 15% in February, and a full 40% of deaths by the end of February were occurring in the vaccinated and triple vaccinated group. Put another way: 60% of deaths are now occurring in the 22% of the population who are unvaccinated and 40% of deaths are happening in the 78% of the populace who are either vaccinated or boosted. You should give that particular attention if you are over 60 or have significant compromising medical conditions.

Yes the vaccines, especially with boosting, are still providing protection, but it has substantially eroded. I’m sure an epidemiologist would come up with a different result, but my simple calculation from these data suggests an unvaccinated person now has only 5.3 times the likelihood of dying compared to the vaccinated. It appears that Pfizer and Moderna are preparing to release new modified vaccines based on the BA.1 Omicron spike for the next round of vaccination, presumably in the fall. I think that trying to chase the last big COVID variant by copying its S protein RNA is an exercise in futility, especially when we are already seeing new variants that have significant escape from Omicron induced immunity circle the globe. The government and the Pharmaceutical industry are selling buggy whips when the COVID virus is sporting around in a new shiny Model T.

There is one last interesting point I’ll go over (perhaps only interesting to real virus aficionados) and then end with a bit of good news. When Omicron first appeared we were told in no uncertain terms that it was much milder than previous variants. This error was the results of the incredibly short news cycle today, and the zeal of scientists and clinicians to be the first reporting some important news. The fatal mistake was failing to take into account the time lag seen from infection to death, and the fact that the initial explosive spread of Omicron in South Africa was primarily hitting a very young demographic group. Since then, there have been dueling articles addressing the issue of Omicron’s intrinsic severity. The most recent was an epidemiology modeling study out of the UK which found Omicron to be just as lethal as the preceding variants. Enter North Korea and Kim Jong-Un onto the Pandemic stage. After claiming to have avoided COVID for two years, the world’s most isolated country is experiencing what may well turn out to be the most explosive episode of Omicron ever seen. They are referring to it as “Fever”, with hundreds of thousands of cases recorded within 2 days of the so called first case. Here we have a very large scale experiment conducted on a captive, completely unvaccinated, poorly nourished population. If this were anywhere else it would answer the question once and for all about how nasty is Omicron in a naive group. Quite nasty I’ll bet, and so is Kim, who is already preparing the scapegoats for punishment. There has been a powerful need for scapegoats in countries around the world since the beginning of this disease. Those people generally faced ridicule, vilification, firing or cancellation, But Kim’s Party scapegoats might be looking at the business end of an anti-tank missile. Serves ‘em right.

The good news is that after weeks of explosive growth in South Africa due to BA.4/BA.5 cases in the last several days have leveled off. We will need another perhaps two weeks to be sure this is not some aberration in testing and reporting, but if the trend holds up that’s a very positive sign.

Those of you enjoying lovely spring weather, congratulations and more of the same. Please forward to family, friends and colleagues you feel may be interested in these summaries of infectious disease issues.